DHS OIG, OIG-21-03, ICE Needs to Address Concerns About Detainee Care and Treatment at the Howard County Detention Center (2020)

ICE Needs to Address Concerns about Detainee Care and Treatment at the Howard County Detention Center October 28, 2020 OIG-21-03 OFFICE OF INSPECTOR GENERAL Department of Homeland Security Washington, DC 20528 / www.oig.dhs.gov(cid:3) (cid:3)October 28, 2020 MEMORANDUM FOR: The Honorable Tony H. Pham Acting Director U.S. Immigration and Customs Enforcement FROM: SUBJECT: Joseph V. Cuffari, Ph.D. Inspector General JOSEPH V CUFFARI Digitally signed by JOSEPH V CUFFARI Date: 2020.10.27 15:09:56 -04'00' ICE Needs to Address Concerns about Detainee Care and Treatment at the Howard County Detention Center Attached for your information is our final report, ICE Needs to Address Concerns About Detainee Care and Treatment at the Howard County Detention Center. We incorporated the formal comments from U.S. Immigration and Customs Enforcement in the final report. Consistent with our responsibility under the Inspector General Act, we will provide copies of our report to congressional committees with oversight and appropriation responsibility over the Department of Homeland Security. We will post the report on our website for public dissemination.

Please call me with any questions, or your staff may contact Tom Kait, Assistant Inspector for Special Reviews and Evaluations, at (202) 981-6000. Attachment DHS OIG HIGHLIGHTS ICE Needs to Address Concerns about Detainee Care and Treatment at the Howard County Detention Center (cid:3) October 28, 2020 What We Found During our December 2019 unannounced inspection of HCDC, we identified violations of ICE detention standards that threatened the health, safety, and rights of detainees. Although HCDC generally complied with ICE detention standards regarding communication, it did not meet the standards for detainee searches, food service, and record requirements for segregation and medical grievances. We determined HCDC excessively strip searched ICE detainees leaving their housing unit to attend activities within the facility, in violation of ICE detention standards and the facility’s own search policy.

In addition, HCDC failed to provide detainees with two hot meals per day, as required. For those in segregation, HCDC did not consistently document that detainees received three meals a day and daily medical visits. Further, HCDC did not properly document the handling of detainee medical grievances. ICE Response ICE concurred with the two recommendations outlined in the report and has identified a corrective action plan to address the deficiencies we identified.

Why We Did This Inspection As directed by Congress, we conduct annual unannounced inspections of U.S. Immigration and Customs Enforcement (ICE) detention facilities to ensure compliance with detention standards. In December 2019, we inspected Howard County Detention Center (HCDC) in Jessup, Maryland, to evaluate compliance with ICE detention standards. What We Recommend We made two recommendations to improve ICE’s oversight of detention facility management and operations at HCDC. For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at [email protected] www.oig.dhs.gov OIG-21-03 OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Table of Contents (cid:3) Introduction....................................................................................................

2 Background .................................................................................................... 2 Results of Inspection....................................................................................... 4 HCDC Generally Complied with Standards on Communication .............. 4 HCDC’s Strip Searches of Low Custody Detainees Violated ICE Detention Standards and Facility Policy .................................................................

5 Lengthy Kitchen Renovations Hampered HCDC’s Ability to Meet Food Service Standards.................................................................................. 8 Incomplete Detainee Records Raise Concerns about Detainee Care ...... 11 Conclusion....................................................................................................13 Recommendations......................................................................................... 14 Management Comments and OIG Analysis ....................................................

14 Appendixes Appendix A: Objective, Scope, and Methodology ................................. 16 Appendix B: ICE Comments to the Draft Report ................................... 18 Appendix C: Office of Special Reviews and Evaluations Major Contributors to This Report ................................................................. 21 Appendix D: Report Distribution.........................................................

22 Abbreviations DRCF DSM ERO HCDC HSA ICE OIG PBNDS Dorsey Run Correctional Facility Detention Service Manager Enforcement Removal Operations Howard County Detention Center Health Services Administrator U.S. Immigration and Customs Enforcement Office of Inspector General Performance-Based National Detention Standards www.oig.dhs.gov OIG-21-03(cid:3) (cid:3) (cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Introduction U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 200 facilities nationwide, but the conditions and practices at those facilities can vary greatly. Although treatment and care of detainees at facilities can be challenging, complying with ICE detention standards and establishing an environment that protects the health, safety, and rights of detainees are vital to detention. In recent years, such care and treatment have been the subject of increased congressional and public attention, and our program of unannounced inspections of ICE detention facilities has identified violations at facilities across the country. In December 2019, we launched our fiscal year 2020 round of inspections with an unannounced visit to the Howard County Detention Center (HCDC) in Jessup, Maryland, and identified concerns regarding detainee care and treatment.

Background ICE apprehends, detains, and removes aliens who are in the United States unlawfully. ICE Enforcement and Removal Operations (ERO) oversees the detention facilities that it manages in conjunction with private contractors or state or local governments. Owned and operated by the Howard County Department of Corrections, the HCDC has had an intergovernmental service agreement with ICE (or its predecessor, Immigration and Naturalization Services) to house detainees for the past 25 years. In addition to the maximum 154 ICE detainees it can hold, HCDC houses county inmates and U.S. Marshals Service prisoners.

HCDC houses only male detainees with criminal histories, classified by ICE as low or high custody.1 ICE pays HCDC $110 per day for each detainee held. ICE’s intergovernmental service agreement with HCDC requires the facility to comply with the 2011 Performance-Based National Detention Standards (PBNDS), as revised in December 2016. According to ICE, the 2011 PBNDS establish consistent conditions of confinement, program operations, and management expectations within ICE’s detention system. These standards set requirements for areas such as: (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 1 Low custody detainees have minor criminal histories with non-violent felony charges and convictions.

High custody detainees have significant criminal histories, gang affiliation, or a history of violence and are always to be escorted around the facility by staff. Regardless of criminal history, ICE detainees are held in civil, not criminal, custody, which is not supposed to be punitive according to the 2011 PBNDS. www.oig.dhs.gov 2 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) (cid:120)(cid:3) environmental health and safety — e.g., cleanliness, sanitation, security, detainee searches, segregation2 (Special Management Units), and disciplinary systems; (cid:120)(cid:3) detainee care — e.g., food service, medical care, and personal hygiene; (cid:120)(cid:3) activities — e.g., visitation and recreation; and (cid:120)(cid:3) grievance systems. ICE’s 2011 PBNDS includes a range of facility compliance ratings from minimal to optimal. For facilities with deficient conditions that do not meet standards, facilities may request and ICE may issue waivers exempting them from complying with certain detention standards.

From 2013 to 2016, ICE granted HCDC five waivers for compliance with 2011 PBNDS for mail and correspondence, visitation, strip searches, key and lock control, and razor usage. Further, in November 2018, ICE contractor for inspection services, the Nakamoto Group Inc. (Nakamoto), determined HCDC was deficient in the standards related to custody classification system, detainee handbook, environmental health and safety, special management units, and food service. As a result, ICE required HCDC to fix these deficiencies in a corrective action plan. HCDC reported it had finished addressing the deficiencies in February 2019.

On December 17, 2019, we made an unannounced visit to HCDC to determine whether HCDC complied with ICE’s 2011 PBNDS. At the time of our visit, HCDC housed 61 ICE detainees in different housing units within the facility. Low custody detainees were held in the facility’s east wing open dormitory with county inmates, and high custody detainees were held in cells within two units on the west wing. There were no inmates in the high custody detainee units.

During our visit, we inspected HCDC facilities including detainee housing units, food service areas, the medical unit, and recreation and religious areas. We also interviewed ICE personnel, HCDC officials, and 10 detainees. (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 2(cid:3)ICE, Performance-Based National Detention Standards, 2011, Section 2.12, Special Management Units (Revised Dec. 2016).(cid:3)(cid:3)Segregation is the process of separating certain detainees from the general population for administrative or disciplinary reasons.

Detainees in segregation at Howard County are placed in individual cells. Detainees in disciplinary segregation can be held for no more than 30 days per incident, except in extraordinary circumstances. Detainees in disciplinary segregation are allowed out of their cells for 1 hour of recreation time at least 5 days a week. Detainees in administrative segregation are separated from the general population to ensure the safety of all detainees and can be held in segregation until their safety, and the safety of others, is no longer a concern.

Detainees in administrative segregation are allowed out of their cells for up to 2 hours of recreation time at least 7 days a week. Detainees in both disciplinary and administrative segregation are also allowed time out of their cells for showers, phone calls, law library, visitation, and religious services.(cid:3) www.oig.dhs.gov 3 (cid:3) OIG-21-03(cid:3) (cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) Results of Inspection Our December 2019 unannounced inspection of HCDC identified violations of ICE detention standards that threatened the health, safety, and rights of detainees. Although HCDC generally complied with 2011 PBNDS communication standards, it did not meet the standards for detainee searches, food service, and record requirements for segregation and medical grievances. We determined HCDC violated detention standards by excessively strip- searching low custody detainees leaving their housing unit to attend activities within the facility.

Although HCDC received a waiver from ICE related to strip searches, HCDC’s current practice of strip-searching low custody detainees without documented reasonable suspicion exceeds the parameters of the waiver and contradicts facility policy. In addition, HCDC failed to provide detainees with two hot meals per day, as required. For those in segregation, HCDC did not document that detainees received three meals a day or daily medical visits, as required. Further, HCDC did not properly document the handling of detainee medical grievances.

HCDC Generally Complied with Communication Standards After reviewing HCDC’s policies and guidance, we determined HCDC generally complied with the 2011 PBNDS for detainee communication.3 Nine of the 10 ICE detainees we interviewed said they were able to communicate regularly with both ICE and HCDC personnel in person and electronically through HCDC communication kiosks, which are electronic devices provided in housing units for detainees to send messages to ICE and facility staff. HCDC’s Detainee Handbook4 instructs detainees on how to communicate with staff informally or formally by submitting written questions, requests, or concerns to facility or ICE personnel using the kiosks or detainee request forms. The Handbook also provides the address and phone number to the local ICE ERO Field Office and states ICE staff are scheduled to be at the facility once a week. (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 3 ICE, Performance-Based National Detention Standards, 2011, Section 2.13.V.A, Staff-Detainee Communication (Revised Dec.

2016). “ICE/ERO detainees shall not be restricted from having frequent informal access to and interaction with key facility staff members.... The local supplement to the detainee handbook shall include contact information for the ICE/ERO Field Office....” 4 HCDC, ICE Detainee Handbook, October 21, 2019. www.oig.dhs.gov 4 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) HCDC’s Strip Searches of Low Custody Detainees Violated ICE Detention Standards and Facility Policy According to detainees and HCDC officials, HCDC strip searches5 low custody detainees to look for contraband6 anytime they leave their housing unit. This practice includes strip-searching low custody detainees when they visit the onsite medical unit, use outdoor recreation, attend religious services, receive contact and non-contact visits, or use the law library.

ICE’s 2011 PBNDS permits strip searches of detainees only when a supervisor approves the strip search based on documented reasonable suspicion7 that contraband may be concealed on the detainee.8 However, low custody detainees at HCDC are routinely strip searched without documented reasonable suspicion and supervisory approval. HCDC officials indicated contraband is a concern because low custody detainees are housed with county inmates who are allowed to leave the facility for work release. HCDC officials said the facility’s practices are to prevent contraband from moving from the east wing to the rest of the facility. HCDC holds both low custody detainees and county inmates in Hendricks Hall, a two-story open floor dormitory with beds placed throughout the unit.

Figure 1 shows Hendricks Hall, which houses ICE detainees upstairs and county inmates downstairs. There is no barrier separating detainees from inmates and the two populations move unimpeded throughout the dorm. (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 5 ICE, Performance-Based National Detention Standards, 2011, Section 2.10.V.D.2, Searches of Detainees (Revised Dec. 2016).

“A strip search is a search that requires a person to remove or arrange some or all clothing so as to permit a visual inspection of the person’s breasts, buttocks, or genitalia.” 6 HCDC Policy E-402 - Searches defines “contraband” as any item not authorized or approved for receipt by an inmate/detainee and any other item specifically forbidden by law. 7 ICE, Performance-Based National Detention Standards, 2011, Section 2.10.V.D.2.b, Searches of Detainees (Revised Dec. 2016) defines “reasonable suspicion” as “suspicion based on specific and articulable facts that would lead a reasonable officer to believe that a specific detainee is in possession of contraband. … It must be based on specific and articulable facts — along with reasonable inferences that may be drawn from those facts—that the officer shall document….” 8 ICE, Performance-Based National Detention Standards, 2011, Section 2.10.II.7, Searches of Detainees (Revised Dec. 2016).

“A strip search shall be conducted only when properly authorized by a supervisor and only in the event that there is reasonable suspicion that contraband may be concealed on the person, or when an officer has reasonable suspicion that a good opportunity for concealment has occurred….” www.oig.dhs.gov 5 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Figure 1. Hendricks Hall where low custody detainees are housed, as observed by DHS Office of Inspector General (OIG) on December 17, 2019. Source: OIG We reviewed HCDC’s strip-search log from August to December 2019 and found that HCDC staff conducted 35 strip searches of low custody detainees, with 1 detainee strip searched 13 times. In addition, HCDC staff did not consistently include the purpose for the strip search, and we were unable to identify why most of the strip searches occurred.

The facility did not provide documentation showing reasonable suspicion that detainees were in possession of contraband or why leaving the housing unit created an increased risk of detainees transporting contraband to other parts of the facility. Because low custody detainees have minimal to no contact with high custody detainees or high-level inmates, even when outside the east wing, it was unclear why the facility believed detainees would spread contraband to other parts of the facility. Further, HCDC reported no incidents of low custody detainees caught with contraband. Figure 2 shows entries from HCDC’s strip- search log. www.oig.dhs.gov 6 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Figure 2.

Entries from HCDC’s Strip-Search Log showing HCDC strip searches ICE detainees9 leaving their housing unit to go to chapel, for an attorney visit, and with no recorded explanation. Source: HCDC Strip-Search Log In December 2015, a Nakamoto inspection determined HCDC was deficient in the standard for detainee searches because HCDC routinely strip searched all detainees during the intake process and without the establishment of reasonable suspicion. Rather than correct the deficiency, HCDC sought, and ICE granted, a waiver10 in 2016 to expand its strip searches of detainees not only at intake, but also for any returning from outside visits including attorney visits. The waiver does not specify that low custody detainees can be strip searched when leaving their housing unit, without supervisor-approved and documented reasonable suspicion of contraband.

Further, in October 2019, HCDC issued its policy on searches,11 which the facility also violates with its current practice of strip-searching low custody detainees. The policy requires officers to frisk search — examine a fully clothed detainee for contraband concealed under clothing — all detainees entering or exiting a housing unit, but does not state that detainees are to be strip searched for only leaving their housing unit. The policy specifies that strip searches shall be conducted on all detainees at intake or returning from kitchen duty, outside visits, and attorney visits. Otherwise, the policy allows strip searches of detainees only when staff have a reasonable suspicion of the immediate presence of contraband, notify their supervisor, and submit a report documenting the need for the strip search.

HCDC did not produce any such documentation of supervisors approving strip searches of low custody detainees. (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 9 In the first entry, HCDC erroneously identified the detainee as an inmate. 10 Waiver for Strip Searches – Howard County Detention Center signed on June 8, 2016, by ICE Assistant Director, Custody Management. 11 HCDC Policy E-402 – Searches. www.oig.dhs.gov 7 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) HCDC’s strip searching of detainees also raises concerns about the comingling of detainee and inmate populations given intent of ICE detention.12 By housing ICE detainees with county inmates, HCDC inappropriately applied policies and practices intended for those in criminal custody to detainees meant to be held in civil custody while their immigration court proceedings are pending.

HCDC should consider physically separating low custody detainees from inmate populations to ensure proper treatment and care as required by ICE’s 2011 PBNDS. We determined HCDC’s practice of strip-searching low custody detainees whenever they leave their housing unit exceeds the authority provided by ICE’s waiver on strip searches and is not allowed by HCDC policy. Detainees told us HCDC’s strip-search practices deterred them from leaving their housing unit to go to the law library or attend religious services. HCDC’s practice of strip- searching low custody detainees leaving their housing unit is unnecessarily invasive and ultimately decreases detainee morale.

Lengthy Kitchen Renovations Hampered HCDC’s Ability to Meet Food Service Standards The 2011 PBNDS requires detainees be served three meals every day, at least two of which are to be served hot.13 All meals must also accommodate the needs of its detained population accounting for differences in age, physical condition, ethnicity, gender, religious preference, and medical considerations. However, for more than 8 months, ICE detainees at HCDC were provided only one hot meal and two cold meals. At the time of our inspection, HCDC’s kitchen was undergoing renovations, as shown in Figure 3, due to persistent drainage issues, and could only be used for food storage, refrigeration, and freezer needs. Due to the renovations, HCDC obtained one hot meal (dinner) each day for detainees by contracting with Dorsey Run Correctional Facility (DRCF), a nearby state prison.

(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 12 Although other ICE contracted facilities hold both detainees and inmates, this is the first facility we have inspected where they were housed together. 13 ICE, Performance-Based National Detention Standards, 2011, Section 4.1.V.D.1, Food Service (Revised Dec. 2016). “Ordinarily detainees shall be served three meals every day, at least two of which shall be hot meals.” www.oig.dhs.gov 8 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Figure 3.

HCDC’s kitchen undergoing renovation as observed by DHS OIG on December 17, 2019. Source: OIG The HCDC kitchen renovation began in June 2019, and was expected to be completed within 30 to 45 days, but was delayed several times because of the time it took HCDC to get kitchen equipment purchased, delivered, and installed. It was not until about 8 months after renovations began that the kitchen reopened. During this entire period, detainees at HCDC received only one hot meal per day.

Of the 61 ICE detainees at HCDC during our visit, 36 detainees had received only one hot meal per day for more than 30 days, with 2 of those detainees receiving only one hot meal per day for more than 5 months. We asked HCDC officials why they did not work with DRCF to provide detainees with two hot meals. HCDC officials stated they lacked the budget to pay DRCF to produce another hot meal and DRCF could not handle the workload of producing and transporting two hot meals per day. We asked ICE officials if they were aware of the facility’s renovations and that detainees would only receive one hot meal daily.

ICE officials said that HCDC informed ICE of the planned renovations in February 2019. According to ICE officials, HCDC said the renovations would begin in June 2019, last for 30 to 45 days, and DRCF would provide HCDC with hot meals in the interim. www.oig.dhs.gov 9 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) However, ICE officials said HCDC did not inform them until after renovations began that DRCF would only provide one hot meal per day. Even after the kitchen’s completion was delayed by several months, ICE officials said they did not plan to make any adjustments regarding the housing of detainees at HCDC because the renovation was expected to be quick and there was limited bed space at other facilities within the Baltimore area. Further, ICE officials did not take any action to ensure detainees received two hot meals or request a temporary waiver for HCDC’s noncompliance with 2011 PBNDS’ expected practices for food services.14 During the kitchen renovation, detainees repeatedly complained about the food served at the facility, including the lack of variety and the facility’s failure to meet dietary requirements.

All 10 detainees we interviewed criticized the facility’s food and many said they often received the same meals for multiple days in a row. Detainees also filed grievances stating their medical and religious diets were not being met while the kitchen was under renovation. Of the 23 non-medical grievances we reviewed from the previous 6 months, 7 grievances concerned detainee requests or complaints regarding a special diet. For instance: (cid:120)(cid:3) A detainee claimed that, although the doctor ordered a 2,400-calorie diet, he did not receive it for 2 or 3 days at a time, and when he did receive it, it did not conform to the doctor’s instructions.

The facility stated the oversight could have been due to switching to a new system. (cid:120)(cid:3) A detainee said upon arrival he requested kosher meals but he did not receive them for 2 weeks. Once he did receive the meals, he was given the same food for 3 weeks straight. The facility stated the detainee’s grievance had merit and the dinner meal was not always rotated correctly.

The lengthy kitchen renovations and the facility’s inability to provide detainees with the required hot meals per day during the renovations raised concerns regarding HCDC’s ability to continuously provide detainees a balanced diet and accommodate special diets based on medical, therapeutic, or religious needs. However, HCDC officials informed us that the kitchen reopened on February 20, 2020, and that it resumed providing detainees the required two hot meals per day. (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 14 ICE, Performance-Based National Detention Standards, 2011, Section 4.1.V.D.1 (Revised December 2016). “Ordinarily detainees shall be served three meals every day, at least two of which shall be hot meals....” www.oig.dhs.gov 10 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Incomplete Detainee Records Raise Concerns about Detainee Care During our inspection, we reviewed HCDC documentation related to detainee care, including records and logs for detainees held in segregation, and medical grievance records.

We found that HCDC did not consistently record meals and medical visits for detainees in segregation. Consequently, we could not verify whether those detainees received three meals daily and received the necessary review by medical staff to ensure their suitability for continued stay in segregation. Further, HCDC was unable to provide an official medical grievance log with complete records. HCDC’s Records for Detainees in Segregation Were Incomplete ICE’s 2011 PBNDS require detainees in segregation be provided three nutritionally adequate meals per day15 and health care personnel conduct face- to-face medical assessments at least once a day.16 The standard also requires facilities log in the segregation housing record whether detainees received these medical assessments and ate each meal.17 We reviewed housing records for 5 of the 13 detainees placed in segregation from June to December 2019, and identified incomplete documentation and logs.

For instance, some logged activities indicated segregated detainees were not receiving three meals or a medical visit daily. All five detainee files reviewed were missing information to show detainees in segregation received or were offered three meals a day. Specifically: (cid:120)(cid:3) Records for a detainee in segregation for 57 days18 were incomplete, only documenting that the detainee received three meals a day for 15 of the 57 days (26 percent). (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 15 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.Q, Special Management Units (Revised Dec.

2016). “Detainees in SMU shall be provided three nutritionally adequate meals per day….” 16 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.P, Special Management Units (Revised Dec. 2016). “Health care personnel shall conduct face-to-face medical assessments at least once daily for detainees in an SMU.” 17 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.P, Special Management Units (Revised Dec.

2016). “Medical visits shall be recorded on the SMU housing record or comparable form….”; and ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.D.3, Special Management Units (Revised Dec. 2016). “The special housing unit officer shall immediately record … whether the detainee ate….” 18 Each day represents a full day in segregation.

We did not include partial days when the detainee entered or was released from segregation. www.oig.dhs.gov 11 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) (cid:120)(cid:3) Records for a detainee in segregation for 15 days were incomplete, only documenting that the detainee received three meals a day for 5 of the 15 days (33 percent). (cid:120)(cid:3) Records for a detainee in segregation for 8 days were incomplete, only documenting that the detainee received three meals a day for 3 of the 8 days (37 percent). (cid:120)(cid:3) Records for a detainee in segregation for 3 days were incomplete, only documenting that the detainee received three meals a day for 1 of the 3 days (33 percent). (cid:3) (cid:120)(cid:3) Records for a detainee in segregation for 6 days did not show the detainee receiving three meals on any of the days.

(cid:3) Additionally, segregation housing records for four of the five detainees we reviewed did not reflect required daily medical visits. Nakamoto found this same deficiency during its November 2018 inspection. Although HCDC reported fixing this deficiency in December 2018, we found the following: (cid:120)(cid:3) Records for a detainee in segregation for 57 days indicated he only received a daily medical visit for 29 of the 57 days (51 percent). (cid:120)(cid:3) Records for a detainee in segregation for 15 days indicated he received a daily medical visit for only 8 of the 15 days (53 percent).

(cid:120)(cid:3) Records for a detainee in segregation for 8 days indicated he received a daily medical visit for only 1 of the 8 days (12 percent). (cid:120)(cid:3) Records for a detainee in segregation for 6 days indicated he received a daily medical visit for only 1 of the 6 days (17 percent). Because of the incomplete records, we could not verify that detainees in segregation received three meals a day or that HCDC’s medical personnel properly monitored these detainees. Facilities must demonstrate they are following standards, and providing food and proper care to detainees in segregation by recording all required activity in segregation logs.

HCDC Was Unable to Provide an Official Medical Grievance Log with Complete Records ICE’s 2011 PBNDS require facilities to maintain accurate records for filed medical grievances and their resolution in a grievance log, the detainee’s www.oig.dhs.gov 12 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) detention file, and keep them separate from other grievances.19 The standard also requires designated medical staff act on the grievance within 5 working days of receipt. During our inspection, we requested HCDC’s medical grievance log and responses to detainee grievances from June 1, 2019 to December 17, 2019. However, HCDC was unable to provide an official medical grievance log, and the only log available was the facility Health Services Administrator’s (HSA) personal log. HCDC provided forms for three medical grievances between those dates.

We had concerns with two of the three medical grievances. One grievance was not resolved until 7 days after the grievance was received and after the detainee submitted a second grievance form. Another grievance showed HCDC medical did not receive a grievance until 3 days after the detainee submitted it. ICE detainees may submit grievances by placing a completed HCDC Grievance Form20 in the medical grievance mailbox, which the facility HSA or designee should check daily.

Among other requirements, the HSA or designee is responsible for maintaining the medical grievance log according to ICE detention standards. The medical grievance log should include: (1) a grievance log number; (2) the date the grievance was filed; (3) the date the grievance was received by medical personnel; (4) the nature of the grievance; (5) the date a decision was provided to the ICE detainee, with the receipt; and (6) the outcome of the adjudication. (cid:3) Without a medical grievance log, we could not determine whether the three grievances represented all medical grievances submitted to HCDC during the relevant timeframe. Due to HCDC’s inability to provide us with a medical grievance log and complete records, we do not have assurance that HCDC efficiently and responsibly addressed detainee medical issues.

Conclusion Complying with ICE’s PBNDS and establishing an environment that protects the rights, health, and safety of detainees are crucial to detention. ICE must ensure HCDC complies with detention standards through immediate attention and increased engagement with HCDC and its operations. (cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3)(cid:3) 19 ICE, Performance-Based National Detention Standards, 2011, Section 6.2.II.7, Grievance System (Revised Dec. 2016).

20 HCDC Grievance Form, H-707a. www.oig.dhs.gov 13 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Recommendations We recommend ICE’s Executive Associate Director of ERO: Recommendation 1: Review and reevaluate HCDC’s strip-search waiver, practices, and policies to ensure compliance with PBNDS requirements. (cid:3) Recommendation 2: Establish a process for routine oversight of HCDC to ensure it: a)(cid:3) provides, and records that detainees in segregation receive, three nutritionally balanced meals per day; b)(cid:3) completes and records daily medical visits for segregated detainees; and c)(cid:3) establishes and maintains a separate medical grievance log, per PBNDS requirements. (cid:3) Management Comments and OIG Analysis ICE concurred with our recommendations and described corrective actions to address the issues identified in this report. Appendix B contains ICE management comments in their entirety.

We also received technical comments to the draft report and revised the report as appropriate. We consider the recommendations resolved and open. A summary of ICE’s response and our analysis follows. ICE Comments to Recommendation 1:(cid:3)(cid:3)Concur.

ICE ERO will work with the ICE Office of the Principal Legal Advisor and DHS Office of Civil Rights and Civil Liberties to review HCDC’s strip-search policy, the 2016 waiver, and applicable court rulings that might affect the ability of county jails and local inter-governmental service agreement facilities to comply with the PBNDS, Section 2.10 “Searches of Detainees,” and make changes, as appropriate. Estimated Completion Date: May 30, 2021. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation when we receive documentation confirming that HCDC has completed appropriate changes.

ICE Comments to Recommendation 2:(cid:3)(cid:3)Concur. ICE ERO is in the process of hiring an on-site federal Detention Service Manager (DSM) to conduct daily compliance reviews at HCDC. DSMs work with ICE ERO field office personnel and facility staff to identify deficiencies, provide “on the spot” resolution of www.oig.dhs.gov 14 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) issues and concerns when possible, and monitor the facility’s implementation and maintenance of corrective action plans. In the interim, ICE ERO assigned a local DSM to temporarily visit the detention facility at least two weeks per month, beginning in November 2020.

The DSM conducted a site assistance visit the week of September 20, 2020, to assess whether detainees in segregation are receiving three nutritionally balanced meals per day, documenting medical visits for segregated detainees, and utilizing and maintaining a medical grievance log. Estimate Completion Date: March 28, 2021. OIG Analysis: We consider these actions responsive to the recommendation, which is resolved and open. We will close this recommendation when we receive documentation confirming the DSM that ICE ERO has put in place at HCDC has completed appropriate corrective actions. www.oig.dhs.gov 15 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Appendix A Objective, Scope, and Methodology The Department of Homeland Security Office of Inspector General was established by the Homeland Security Act of 2002 (Public Law 107-296) by amendment to the Inspector General Act of 1978.

DHS OIG initiated this inspection at Congress’ direction. As part of our unannounced inspections, we also review and analyze concerns raised by immigrant rights groups and complaints to the DHS OIG Hotline about conditions for aliens in U.S. ICE custody. We generally limited our scope to the 2011 PBNDS for health, safety, medical care, mental health care, grievances, classification and searches, use of segregation, use of force, language access, and staff training. We focused on elements of these standards that we could observe and evaluate during our onsite inspections.

Our visit to HCDC was unannounced so we could observe normal conditions and operations. Prior to our inspection, we reviewed relevant background information, including: • OIG Hotline complaints • ICE 2011 PBNDS • DHS Office for Civil Rights and Civil Liberties reports • ICE Office of Detention Oversight reports • Information from nongovernmental organizations • Information provided in congressional requests • Information provided from state and local governments requests We visited HCDC from December 17 to December 18, 2019. During the visit we: • inspected areas used by detainees, including intake processing areas; medical facilities; kitchens and dining facilities; residential areas, including sleeping, showering, and toilet facilities; legal services areas, including law libraries, immigration proceedings, and rights presentations; recreational facilities; and barber shops; •(cid:3) reviewed facility’s compliance with key health, safety, and welfare requirements of the 2011 PBNDS for classification and searches, segregation, access to medical care and mental health care, medical and nonmedical grievances, and access to translation and interpretation; www.oig.dhs.gov 16 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) •(cid:3) interviewed ICE and detention facility staff members, including key ICE operational and detention facility oversight staff, detention facility wardens or someone in an equivalent position, and detention facility medical, classification, grievance, and compliance officers; •(cid:3) interviewed detainees held at the detention facility to evaluate compliance with 2011 PBNDS grievance procedures and grievance resolution; and • reviewed documentary evidence, including medical files, and grievance and communication logs and files. We conducted this review under the authority of the Inspector General Act of 1978, as amended, and according to the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. www.oig.dhs.gov 17 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Appendix B ICE Comments to the Draft Report www.oig.dhs.gov 18 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) www.oig.dhs.gov 19 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) www.oig.dhs.gov 20 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Appendix C Office of Special Reviews and Evaluations Major Contributors to This Report John D. Shiffer, Chief Inspector Amy Burns, Chief Inspector Stephanie Christian, Lead Inspector Renita Caracciolo, Senior Inspector Ian Stumpf, Senior Inspector Erika Algeo, Independent Referencer www.oig.dhs.gov 21 (cid:3) OIG-21-03(cid:3) OFFICE OF INSPECTOR GENERAL Department of Homeland Security (cid:3) (cid:3) Appendix D Report Distribution Department of Homeland Security Secretary Deputy Secretary Chief of Staff Deputy Chiefs of Staff General Counsel Executive Secretary Director, GAO/OIG Liaison Office Assistant Secretary for Office of Policy Assistant Secretary for Office of Public Affairs Assistant Secretary for Office of Legislative Affairs ICE Liaison Office of Management and Budget Chief, Homeland Security Branch DHS OIG Budget Examiner Congress Congressional Oversight and Appropriations Committees (cid:3) (cid:3) www.oig.dhs.gov 22 (cid:3) OIG-21-03(cid:3) Additional Information and Copies To view this and any of our other reports, please visit our website at: www.oig.dhs.gov.

For further information or questions, please contact Office of Inspector General Public Affairs at: [email protected]. Follow us on Twitter at: @dhsoig. OIG Hotline (cid:3) To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click on the red "Hotline" tab. If you cannot access our website, call our hotline at (800) 323-8603, fax our hotline at (202) 254-4297, or write to us at: Department of Homeland Security Office of Inspector General, Mail Stop 0305 Attention: Hotline 245 Murray Drive, SW Washington, DC 20528-0305